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Episode: Adolescent marijuana use: a discussion with addiction specialist Dr Sara Polley

Author: Michelle Chestovich MD
Duration: 00:45:43

Episode Shownotes

Physician coach Michelle Chestovich MD discusses facts and myths surrounding adolescent marijuana use with Dr. Sara Polley, who is a national leader in the field of pediatric addiction psychiatry and the treatment of individuals who experience both mental health and substance use concerns. This is a must listen for parents

and physicians who care for kids.Click here to book an appointment with Dr Polley:https://elliementalhealth.com/Want CME credits via CMEfy for this episode?Click here: The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/mfPGUf

Full Transcript

00:00:00 Speaker_01
You are listening to episode 153 of the Remind Yourself Podcast. Welcome to the Remind Yourself Podcast, the podcast for physician moms just like you who want to ditch mom guilt, stop yelling, and start enjoying their lives today.

00:00:21 Speaker_01
I'm your host, Rachelle Chestevich, certified life coach, family physician, and mom of four. If you want to overcome overwhelm for once and for all, this is the place for you. Hello, Mama Docs, and welcome back.

00:00:40 Speaker_01
I am thrilled today to have a guest that has been on before. She is my first returning guest, and she has so many wonderful things that she is going to talk with us about to help ease our minds. Welcome Dr. Sarah Pauly. Yeah, thanks for having me.

00:00:56 Speaker_01
I can't believe I'm your first repeat guest. I feel honored. You totally are. And this is like my third year of the podcast. So the fact that like you've got really important things to say, I guess, is what I'm trying to say.

00:01:08 Speaker_01
We had a beautiful conversation about how we could we can't recall the episode, but, you know, not too many months ago that you shared your story and talked about, you know, being able to transition to other opportunities.

00:01:18 Speaker_01
But today I wanted to have you back because you have your finger on the pulse of what's going on in society with substance abuse, because that's the work that you do, and in particular with adolescents.

00:01:31 Speaker_01
And I would say, I don't know if it's a resurgence or just a surging of what I hear a lot of talk about, particularly marijuana use. So I'm just gonna let you start the conversation and I will think of questions as I see fit.

00:01:44 Speaker_01
But I'm so grateful for you to be able to give us like the straight facts, because there's a lot of myth out there, I would have to say.

00:01:53 Speaker_00
Yeah, no, I appreciate being able to talk a little bit more about this because I think people can vacillate, right, especially when it comes to marijuana.

00:02:00 Speaker_00
I, you know, I see things and I'm active like in, you know, even physician mom social media and like parent social media, everything from, you know, marijuana use in teenagehood is totally normal.

00:02:11 Speaker_00
It's not anything to be worried about all the way to like a, oh my God, I found out my kid used marijuana.

00:02:17 Speaker_00
now I've freaked out, I've searched their room, they're grounded, I'm taking them for a substance evaluation because they're going to go to residential rehab or something, right? So it's like, yeah, because it's a scary topic.

00:02:29 Speaker_00
And I think it's because it hasn't been legal. I don't think that, you know, some of us have more experience than others.

00:02:34 Speaker_00
But I think a lot of us that are on the straight and narrow, it just wasn't really something that we spent a lot of time thinking about or doing. And so

00:02:41 Speaker_00
now that it's becoming legalized, it's becoming more popular among young people to use it, it's kind of scary and can be uncharted territory.

00:02:49 Speaker_01
Yeah, so I would love to have you just share all the things that you know, right? Like, we don't have to get into the statistics, but it's sort of interesting.

00:02:58 Speaker_01
And again, I think just for listeners, because I would probably fall into the camp of like, oh my gosh, catastrophe, right? My worst brain scenario goes to like, I found this or I'm concerned about this and now we need to like go to the extreme.

00:03:10 Speaker_01
So I will just let you start speaking and just I know that you are going to help give us some real information that's going to help us take a deep breath and or know what to do if there are real concerns.

00:03:21 Speaker_00
Yeah, so just to kind of start, I think one kind of fact that was always helpful and kind of surprising when I first heard about it is that the majority of teenagers actually go through their entire teenage years and never smoke marijuana.

00:03:36 Speaker_00
there's a perception that everybody does that or that most people do it. And it's a little different when we talk about college age kids and young adults. But when we're talking about teens in high school, most of them have never tried marijuana.

00:03:49 Speaker_00
Those that have tried marijuana have only done it a couple of times, maybe once or twice within a year period. The number of kids who use marijuana with any regularity when they're teens is actually very small. It's like less than 10%.

00:04:03 Speaker_00
So that's, I think, a good frame of reference because whether or not it's a patient that you're treating or if it's your own child, if your child's using, particularly if you know or they tell you that they're using with any regularity, they're really putting themselves in a more at-risk group because that isn't really what most kids are doing.

00:04:21 Speaker_00
And so the way I think about it is that

00:04:24 Speaker_00
you and i can talk a little bit more to about like what are all the different types of marijuana that kids use and i'm sure there's some that i'm not even aware of but like what what are kids doing but but generally i think of use of marijuana as a risk factor for development of potential problems.

00:04:40 Speaker_00
And all of us live our lives, right, with a certain set of risk factors and protective factors.

00:04:45 Speaker_00
And whether, again, it's your patient or your own child, the goal is to have the list of protective factors be a much longer, more robust list than the list of risk factors for your child, right?

00:04:57 Speaker_01
I love that. I'm just going to like stop right there and just some like taking a deep breath and thinking that's probably so true in not only substance use, but in other things, whether it's mental health issues, what have you.

00:05:10 Speaker_01
Like, it's just reassuring, I think, again, as a mama and as a physician to realize like, OK, there can be both protective and Now I can't think of the word that you use.

00:05:22 Speaker_00
Yeah, risk factors, yeah. Risk factors, yeah. Yeah. Well, and right, and like another idea too, being that like, that would be ridiculous to think that we could prevent any risk in our child, right? Or for our, even for ourselves, right?

00:05:33 Speaker_00
There's certain things that we can change. There's certain things that we can't change.

00:05:37 Speaker_00
And a lot of times kids have enough protective factors that they can run through the risk factors and it doesn't cause a lot of disruption for them, which I think is where, you know, when you talk about marijuana and kids,

00:05:48 Speaker_00
You know, you'll hear stories like, well, for example, I smoked marijuana when I was a teen and it didn't cause me problems, or my kid smokes occasionally but they're doing fine in school, it's not a big deal.

00:05:58 Speaker_00
And I think, yes, that's true for a lot of people, and likely that's because their list of protectives outweighs their list of risks, right?

00:06:05 Speaker_00
They come from a loving family, they're probably academically pretty smart, they have a good pro-social group of kids, like all the things that we think of when we think of protective factors.

00:06:13 Speaker_00
And so having on the list smokes marijuana, yes, it's a risk, but it's not enough to outweigh all of the protection.

00:06:20 Speaker_00
And then you think about kids who maybe don't have as robust of a list of protective factors or kids who have additional things on their risk factor list, such as strong family history of addiction, family history of difficulty with mental health, you know, difficulties academically, maybe a lower, you know, intellectual function.

00:06:38 Speaker_00
And so really, I think of marijuana as being

00:06:42 Speaker_00
a potentially modifiable risk factor that for some kids it's not really going to matter that much, and for other kids it might be the one thing or one of two or three things that tips them over the edge to then have really some big struggle to go down the path of developing an addiction, whether that's to marijuana or other substances, exacerbation of underlying mental health conditions, you know, further pushing them away

00:07:04 Speaker_00
from pro-social activities and pro-social peers to the point that they're feeling isolated and then become even more fully ingrained in a culture of using substances.

00:07:14 Speaker_00
So I try to think of it kind of in a more gray area versus it being all like it's either a super bad thing or it's a super good thing. I think it really depends on the kid and it depends on the context.

00:07:25 Speaker_01
I love that. And it takes into effect all the things and helps us, again, get out of our black or white thinking and catastrophic thinking that many of us physicians have. So like, OK, let's just look at the facts. Love that.

00:07:36 Speaker_01
OK, so you mentioned maybe sharing some ways. I mean, maybe that's where you want to start or. Yeah, sure.

00:07:43 Speaker_00
Yeah, so first and foremost, kids are the most likely, with any substance, are the most likely to use substances that are viewed to be normal and low risk, right?

00:07:55 Speaker_00
I mean, kids are not stupid, so like, if you ask a kid, do you think it's a good idea to inject something, like a drug, into your body? They're going to go, no, like, that's scary. I'm not going to do that.

00:08:05 Speaker_00
You know, those that are further in the progression of an addictive illness would say, I might do that. I've seen people do that. But kids who are not kind of full fledged, you know, severe addictive disorders are going to not do that type of thing.

00:08:17 Speaker_00
So they're going to do things that appear normal, appear low risk. And so things that are glorified societally, we know that as perception of risk and as kind of promotion in the media and social media go up,

00:08:29 Speaker_00
the use of that particular substance among young people also goes up.

00:08:33 Speaker_00
So that's what, when we talk about marijuana, that's kind of the interesting part about being in Minnesota right now, is that because it's legalized for adult recreational use, and commercialization is going to be, is legal in Minnesota, what we're going to see is, you know, more advertisements for marijuana.

00:08:48 Speaker_00
We're going to see billboards for marijuana, potentially. I've already received mailings to my house that are like, hey, do you want us to deliver marijuana to your house for fun? Right?

00:08:58 Speaker_00
Which in a lot of ways, it echoes how we've always treated alcohol, right? We've always kind of treated alcohol that way. Like you can get a delivery alcohol to your house, you get ads for alcohol, you know, whatever.

00:09:09 Speaker_00
So that's one piece that we know about young people is that they use things that are promoted, they're in the media, things that seem low risk.

00:09:16 Speaker_00
And then they're also the most likely to use things that are new because of this idea of like, oh, that's cool, or that's fun, or that's not kind of like what everybody else is doing.

00:09:26 Speaker_01
The old fashioned way.

00:09:27 Speaker_00
Right. Yeah, exactly.

00:09:29 Speaker_00
So like, for example, one of the popular ways of using marijuana, whether that's like traditional Delta 9 THC, which is kind of the traditional marijuana or some of the other types of marijuana, like the Delta 8 marijuana, which also is psychoactive and impacts the brain.

00:09:43 Speaker_00
It's just a different version, essentially, is they use it via vape. So electronic cigarette delivery devices, which can be purchased now legally, not by kids, but by adults.

00:09:54 Speaker_00
And then also things that are manufactured illicitly, which those are obviously more dangerous because they can contain way more nasty chemicals potentially than ones that are purchased legally.

00:10:04 Speaker_00
But that's a really popular way for young people to use marijuana because it's easy to do. It's you can deliver it very quickly. I mean, the same reasons they like to use that with nicotine, right?

00:10:14 Speaker_01
It's just going to say like vaping with nicotine is something that has been on the rise for, I don't know, many years that I think that people just think like, oh, it's not as bad as smoking. I'm like, yeah, I don't think it's great.

00:10:28 Speaker_00
Yeah. Yeah. So, and again, and you know, I always tell kids, like, I think the jury is still out about that, right? Because, like, if you look back at, like, tobacco cigarettes, like, we didn't think those were any big deal.

00:10:39 Speaker_00
We were like, ooh, there's, like, doctors smoking them and, like, telling their patients to smoke them, right?

00:10:43 Speaker_00
And, like, we may be in a similar point in history where we look back on telling people to use electronic delivery devices for things and be like, wow, that was a mistake because now we've got all these people with emphysema or, like, whatever it is, you know?

00:10:57 Speaker_00
And I think kids sometimes like that kind of message because I think there's this intrinsic like fight the man kind of thing that kids have, you know, where it's like, I don't want to do I don't want to do what I don't want to be manipulated by the media, even though they kind of are being.

00:11:13 Speaker_00
Yeah, one hundred percent. So if you like it as like you don't want to be manipulated. Right. And like this could just be a repeat of tobacco cigarettes all over again. A lot of kids will be like, yeah, that's actually a good point.

00:11:25 Speaker_01
Yeah, no, for sure. So do you think that the vaping is like the most common way that young folk get the drug? Use marijuana? I don't know how I should be saying this.

00:11:37 Speaker_00
Yeah, yeah, no, you could, yeah, use it would be fine. I don't know if it's the most popular. I think it's kids might first use like the bud or the flower, which would be kind of the traditional way to use it, like smoking a joint or smoking a bowl.

00:11:50 Speaker_00
I think that's probably how most kids will start because that's probably the most easily accessible. But I think kids learn really quick that that's inconvenient to continue to do because it smells bad.

00:12:01 Speaker_00
And so if you're trying to sneak around, you don't want to smell like marijuana. You can't, you know, a lot of kids will do marijuana in public, not at their house because they, you know, don't want their parents to find it or whatever.

00:12:12 Speaker_00
And so like, yeah, you could go to a party, and maybe the kid's parents aren't home, and so then you use the butter, the flour, and it smells bad. But pretty quickly, it becomes a situation where it's harder to hide.

00:12:22 Speaker_00
So it becomes way more convenient to use an electronic delivery device because it doesn't smell like anything. Same with apple.

00:12:28 Speaker_01
Yeah, that skunk smell, I tell you what, since it's become legal in Minnesota, don't love that. I'd go for a run or a walk, and I'm like, oh my God, there's a skunk.

00:12:36 Speaker_00
I know.

00:12:36 Speaker_01
You're driving, I smell it. And my kids are like, why do you keep commenting? I'm like, because I think it's gross.

00:12:42 Speaker_00
Yeah, no, it does. Yeah, it is interesting, right? And like traveling to other states like, you know, California or New York, I know like you, I would notice that and now I'm like, okay, I guess we're doing that here now. Yeah.

00:12:53 Speaker_01
What about the like edibles and gummies? I know that's a very, well, I don't know if it's a popular thing, but I've, I know about them.

00:13:01 Speaker_00
Yeah, I would say it's popular.

00:13:03 Speaker_00
I think that, you know, as it gains popularity among adults, because again, I think there's this sense of it being a little bit more healthy or not as dangerous to use an edible or eat a gummy than it would be to smoke something for an average adult probably who might not be a regular marijuana user.

00:13:20 Speaker_00
I think that more homes have edibles within them, just like how homes have alcohol where kids might be exposed or might try it. So I think kids are getting a hold of edibles and using them often, I think, because they're in people's houses.

00:13:33 Speaker_00
And so, you know, knowing where their mom and dad stash it and then going and deciding they're going to try it just like they would with alcohol. So yeah, I'd say edibles are another You know, and, you know, of course the marketing, right?

00:13:45 Speaker_00
Like there's laws where you're not supposed to be able to market edibles as looking like candy or being candy, but it's like there's all these little loopholes where, like, I'm pretty sure when I've looked at some of the packaging that's available in Minnesota on edibles, it looks like candy.

00:13:59 Speaker_00
It's marketed as chocolates or gummies or things like that. And so I think that also makes it a little bit more appealing to young people because it seems like candy or something fun.

00:14:09 Speaker_01
Yeah. So you tell me, but I think that there is some myth with say youngsters. Cause then I sound like I'm 90, like, you know, teens, adolescents that like, it's just not a big deal. Now tell us, tell us what like the facts are.

00:14:22 Speaker_01
How does this affect your brain? How can it affect us long-term?

00:14:26 Speaker_00
Yeah. And so, yeah, I always kind of give the caveat that, like, not everyone is going to have negative effects. Just like, you know, people ride their bike without a helmet for their whole life and they never get brain damage, right?

00:14:38 Speaker_00
So, like, the point is not that it's, like, to, like, wag your finger and scare kids, you know? Like, you're going to have brain damage if you use drugs. Like, that's not

00:14:47 Speaker_00
The point, the point is that particularly for kids who are high risk, and particularly, and then there's also kids where, you know, like we, when it comes to other health related behaviors, right, like the kid who lots of us don't wear a helmet, but then it turned out that kid wasn't wearing a helmet and then happened to get hit by a car and now is paralyzed, right?

00:15:04 Speaker_00
So it's like it happens sometimes. And again, we're just trying to decrease risk. by whatever means we can, so like trying to help emphasize making healthy choices.

00:15:12 Speaker_00
But so what can happen for some people, so there's a few different categories, I guess, when I'm providing education to patients or other people about the way that marijuana can impact the teenage brain.

00:15:23 Speaker_00
I think the first thing that I talk about is that, you know, marijuana increases the risk of difficult to treat mental health conditions.

00:15:33 Speaker_00
And so kids that are using marijuana may have had pre-existing mental health conditions, and those mental health conditions become harder to treat. So whether that's ADHD, anxiety disorders, depressive disorders,

00:15:45 Speaker_00
kids who smoke are more likely to have suicidal thoughts with their depression than kids who don't smoke. And so I try to tell kids, especially if they have things like ADHD or depression, that smoking in the moment might feel good.

00:15:57 Speaker_00
And especially when you're intoxicated, it makes it feel like it's helping you. But in the long run, it's actually making your symptoms worse. And what I don't want for you is to be someone who's

00:16:07 Speaker_00
50 and still has depression and is needing to get, you know, very intensive mental health treatments. I want this to just be a blip for you and for your brain to get better. And so the way to help that to happen is by not using toxins like marijuana.

00:16:20 Speaker_00
That will help your brain to do a better job of getting itself better. to a place where you're not struggling with depression and anxiety anymore. So that's kind of the first piece.

00:16:27 Speaker_00
We know, and I think most of us that work in healthcare know, right, that the brain is sensitive during teenage and early adulthood years. The brain's not fully developed or fully

00:16:38 Speaker_00
online until mid-20s, and particularly the prefrontal cortex, which you know executive function of the brain, is not kind of fully myelinated or developed until mid-20s.

00:16:48 Speaker_00
And so there's a lot of research that points to negative impacts from exposure, marijuana exposure creating negative developmental trajectories for kids when they get that exposure during teenage years where their prefrontal cortex doesn't develop in the way that it was supposed to.

00:17:04 Speaker_00
So in some ways ends up creating things that look like ADHD.

00:17:08 Speaker_00
And so I've actually taken care of plenty of young adult patients where they don't really have a childhood history of ADHD, but they had pretty regular heavy marijuana use starting from when they were 14 or 15 up until they were maybe 17 or 18.

00:17:22 Speaker_00
And then they decided to stop using or they went to treatment and they don't do that anymore. And now we do cognitive testing and they have pretty severe ADHD.

00:17:30 Speaker_00
And I don't think they had it when they were little, but I think they actually gave themselves brain damage, and now they actually have a problem. So I'm needing to treat them with ADHD medications.

00:17:38 Speaker_00
And so we know it can lower people's IQ when you smoke at that age. It, again, just kind of disrupts executive function. And that's stuff that can stick with the person's brain even after they stop using.

00:17:49 Speaker_00
And so again, the way that I try to talk with my patients about it is it's like, I would not say like never smoke. Smoking is bad for you, right?

00:17:57 Speaker_00
Like all of us make choices when we're adults, like some, you know, drink alcohol, do things that are maybe kind of risky.

00:18:03 Speaker_00
But like, if you want to be an adult that uses recreational marijuana for fun, then one of the best things you can do is to not do it right now, because that also leads into what the other risk, another risk factor is, which is that it increases your risk of addictive disorders in adulthood.

00:18:17 Speaker_00
And so, When we use something like marijuana or really any addictive substance when you're young, again, because your brain is not fully formed, what you're doing is you're strengthening reward pathways while weakening control pathways.

00:18:31 Speaker_00
And so what you end up getting is an overly strengthened reward pathway that is hard to control. And so it's going to be harder for you to control impulses, to control use of any kind of substance that has the potential for addiction.

00:18:44 Speaker_00
So it's a common story that kids will use marijuana when they're teens, right? It might not have been a problem for them when they were that age. And then here they are now 20, 22, 25, and they have a really severe alcohol use disorder.

00:18:59 Speaker_00
Not because they misused alcohol when they were young, but because they misused marijuana and that kind of primed their brain to be extra sensitive to the impact of alcohol once they started drinking. Or, you know, same for opioids, right?

00:19:11 Speaker_00
Like someone used substances like marijuana when they were teens, and then they kind of petered out and didn't do it. And then they were prescribed an opioid a little later in life.

00:19:19 Speaker_00
And because they had primed their addiction pathway, they were one of the people who had problem with becoming addicted to their prescribed opioid. So again, it's like...

00:19:28 Speaker_01
Yeah, that makes sense. I mean, that's so interesting. And I suppose same would be true if like someone was drinking at a younger age, too.

00:19:33 Speaker_00
Yes. Yeah.

00:19:35 Speaker_01
So whatever the substance is, if you're doing it younger and your brain is not fully developed, it's sort of just creating this big. This is the way my brain thinks of it, like a big landing page, a big beacon of like, remember this, this feels good.

00:19:46 Speaker_01
And so then in the future, that could become a problem.

00:19:49 Speaker_00
Yes, yep, that's exactly right.

00:19:51 Speaker_01
Thank you for explaining that. That's, yeah, that's not awesome. Yeah. You know, you also mentioned that, you know, with the overlap too, like, you know, let's not make your brain that's already struggling with anxiety or depression or ADHD, like,

00:20:04 Speaker_01
less healthy so it can heal. But I also would imagine that perhaps you tell me, do people maybe turn to these sorts of things as like a coping mechanism, right?

00:20:14 Speaker_01
I know for sure when I was in primary care, like I saw a lot of folks with anxiety turn to alcohol, for instance, to like, quote unquote, feel better temporarily.

00:20:24 Speaker_00
Yeah, no, that's exactly right. Yeah. And that, you know, it's really common that kids and that's part of kind of the negative psychosocial impacts of using marijuana when you're young is right.

00:20:33 Speaker_00
Like if you decide or you're struggling and then you start to use a substance to help you cope. And I tell patients this, I'm not going to have a medication that provides as instantaneous of relief as a substance that's a substance of misuse.

00:20:49 Speaker_01
Right, because that's going to flood your brain. Temporarily, you'll feel slightly better.

00:20:55 Speaker_00
Yes, right, exactly. And so the idea being that you've basically conditioned your brain now to having your primary coping skill be this substance which has too many negative downsides.

00:21:07 Speaker_00
Yes, it might work in the moment, but let's look at all of the problems that it might cause. And now I'm trying to help you and telling you to use coping skills, and your brain is laughing at my face. I don't want to do 478 breathing.

00:21:20 Speaker_00
What are you talking about? Coloring doesn't do anything. Why would I do that? And then, so it can be really hard to kind of, after the fact, develop healthy coping skills when your brain has become reliant on an unhealthy coping skill.

00:21:32 Speaker_00
And so, you know, it's a heavy lift. Like it happens, but it's like you have to really work hard. It's almost like you can't teach an old dog new tricks, right? Your brain has already learned to use marijuana or whatever.

00:21:42 Speaker_00
to cope, and now you're trying to get it to learn something new that doesn't work as well, and that can be a really hard process.

00:21:48 Speaker_00
So, and then, you know, similarly, right, like, kids, a trajectory developmentally, or developmental-wise is like, a kid will start to use marijuana, for example,

00:21:57 Speaker_00
it may further isolate them from other peers who are not choosing that type of behavior. You know, kids can have ramifications where they're kicked out of sports.

00:22:06 Speaker_00
Other kids who maybe are making healthy choices don't want to associate with them because they're using, the parents of the other kids don't want their kid associating, right? And so then that kid becomes further and further isolated. Amplifies that.

00:22:18 Speaker_00
Yes, exactly. Which contributes to their mental health problems and additionally puts them into a place where the only kids that they feel connected with are other kids that are using substances. So they become even kind of further down that path.

00:22:30 Speaker_01
Yeah, right. Because we're social creatures. So you're going to find your people. OK, well, this is really interesting. Sounds a little dire right now as I'm thinking about it.

00:22:38 Speaker_01
And again, my adult brain is like, OK, well, it totally makes sense to just not even try it. Right. Like, you know, but that's my adult brain. So what are your thoughts on that? And one thing I'm also thinking about is

00:22:50 Speaker_01
So like, what are your thoughts on that? And number two, like what wisdom can we share with parents and physicians to have these conversations with our kiddos? Because again, as a primary care doc, I was doing like teen sports physicals all the time.

00:23:04 Speaker_01
And I feel like, I mean, I talked about smoking and alcohol. I mean, this THC thing is to me relatively new. So yeah, just talk about those sorts of things. All of the things, tell us all of the things. How we can help impact our community.

00:23:19 Speaker_00
Well, so I think, and I've explained this to parents sometimes, I think the hard part is, especially if you're a parent that's like educated or you work in like healthcare or mental health or whatever, you want to try to be your kid's therapist and your kid's mom or dad or parent, guardian, right?

00:23:35 Speaker_00
What are you talking about? I want to solve all the problems. Okay, I'll stop talking. No, I know. Well, it's hard. Yeah, I mean, yes, I feel it too. And I often tell parents that those are two very distinct roles for a reason.

00:23:48 Speaker_00
And so the types of conversations and approach that like I might have or like a therapist might have with your child is different than I think what a parent's approach

00:23:57 Speaker_00
should be, there's some overlap, but so for example, right, like when I'm meeting with a kid that's smoking marijuana, I am not telling that kid, you need to stop smoking marijuana, it is illegal for you, it is against the rules, bad thing, you know, like that's not what I'm doing.

00:24:11 Speaker_00
I'm trying to work on aligning with them, validating their perspective, doing, you know, motivational interviewing with them. I do think, though, as a parent, it is important to be clear with your kids.

00:24:22 Speaker_00
And again, there's a difference between being clear or definitive and then being emotional about it.

00:24:27 Speaker_00
So be clear with your kids before it's ever an issue that it's against the rules in our family for kids to use marijuana or drink alcohol or whatever the rules are going to be, because I can't tell you how many times that kids will come in here and say, well, I think my parents would be fine with it if they just didn't know about it or if it wasn't causing problems for me.

00:24:45 Speaker_00
they must have gotten that from somewhere, right? It's probably because their parent was never explicit with them. They're like, no, I'm not okay with you smoking marijuana. Like, I'm not okay with that, right?

00:24:53 Speaker_00
So I think it's important for parents to be clear. I love it. Clear is kind. It's my favorite Brene Brown quote. Yes. And I think just like you would write any other health safety related behavior,

00:25:05 Speaker_00
you want to come up with a plan to try to not only encourage your kid to ask for help if they need it, so you don't want to have a big emotional reaction, but also like consequences if they are flagrant with the rules, right?

00:25:16 Speaker_00
So like, just like how, you know, when your kid's not going to buckle their seatbelt or they unbuckle themselves in the car, you pull over and you say,

00:25:22 Speaker_00
you don't scream and yell, but you say like, nope, we're not driving the car until you put your seatbelt back on. It's safety related, you know, like you're firm about it.

00:25:29 Speaker_00
So I think the same is true when it comes to use of substances, where again, it's not like flipping the kid's room, telling them they can't hang out with their friends anymore, that they're grounded for two months or something.

00:25:39 Speaker_00
it's more about like a, hey, we've talked about this, right? It's not, it's against the rules to use marijuana in this family. I found out that you were using, this is the consequence for that.

00:25:48 Speaker_00
You know, I, and if it continues to happen, then that starts to make you think maybe this, my child has a problem with this and needs some professional help because despite the fact that they are, no, it's not, it's not okay with us and that they're having these consequences, they still continue to choose to do it.

00:26:03 Speaker_00
And so, So I think that's important to distinguish.

00:26:06 Speaker_01
I love that.

00:26:07 Speaker_01
And that's just like really like clear to us parents to like, oh, you just like because sometimes we assume like we're so loving and kind, but there's so many things we're trying to like teach our children, like, OK, let's just be real clear about it.

00:26:18 Speaker_01
And this would be the consequence. And then if something comes up, it doesn't have to be emotional. And or if you're feeling emotional, like.

00:26:25 Speaker_01
take that to your room and talk to your partner or call your therapist or your friend and like get the emotions out and then just adjust the behavior. I love that. I bet the teens react to that a lot better.

00:26:35 Speaker_01
I mean, I'm sure they don't love it to be confronted by parents, but yeah.

00:26:39 Speaker_00
Yeah. Well, the biggest thing I think that I hear from teens that's upsetting to them and is when their parents have big big feelings that they can't control. Which, of course, all of us are humans and it happens.

00:26:50 Speaker_00
But, you know, like, I think a lot of teens, it takes away some of the legitimacy, I think, of what the parent is trying to do when they just blow up and it's this big dramatic thing.

00:27:00 Speaker_00
Because a lot of times then those kids will tell me, oh yeah, my mom was just pissed, but, like, she's not actually gonna drug test me.

00:27:06 Speaker_00
Like, she just said she was, you know, so it's sort of like, no, but being calmer and then actually following through with what you said you were gonna do, those things are the most important.

00:27:15 Speaker_01
Yeah, that totally makes sense.

00:27:17 Speaker_01
And then now your role, right, as a psychiatrist, of course, you're gonna be aligning with these kids and helping them come up with some solutions on how to get off the substance or what other additional support they need, that sort of thing.

00:27:29 Speaker_01
What about primary care docs and pediatricians? I mean, again, we love to think that everybody's having these conversations, but I'm not in the room when, I love my kid's physician, but I don't know if this stuff is being asked.

00:27:43 Speaker_01
I'm just curious, what are your thoughts on that? How can we just easily bring it up?

00:27:48 Speaker_00
Yeah, so really standard of care is to be asking anyone over the age of 12 years old about substance use in the primary care office.

00:27:56 Speaker_00
And so there are really great like very short screening tools that some clinics will use that they'll just automatically give to the kid to fill out privately that asks them questions about their use of substances. I think it's important.

00:28:09 Speaker_00
So like the screening tool can also be administered orally by the provider. And it's really like in the past 12 months, how many times have you used alcohol? And in the past 12 months, how many times have you used marijuana?

00:28:20 Speaker_00
And if the kid answers anything other than zero to those two questions, then you want to ask more specific about other types of substances to get a sense of what they're using. And really, the recommendation is

00:28:32 Speaker_00
If the child is using, if they say no, that's great.

00:28:35 Speaker_00
And you want to reinforce that that's a really healthy decision that they're making and, you know, help them to think about maybe like what they might do if they were ever offered it or what the reasons are behind why they haven't done it to really bolster that for them.

00:28:47 Speaker_00
If the child says, yes, I've done it a couple of times, it's important to just offer some education in that moment quickly about, you know, what the risks are that are associated with use of marijuana when you're young.

00:28:58 Speaker_00
If a child's using it more frequently, like I think the cutoff with the screening tool is something like weekly.

00:29:03 Speaker_00
If they say they're using it weekly, then you might want to talk with them about asking more questions to screen for a substance use disorder.

00:29:10 Speaker_00
Or if you don't have the time to do that, to refer them to a specialist like a therapist or somewhere else that could really screen them for that. And again, trying to maintain confidentiality for the young person, which can be tricky. I oftentimes

00:29:24 Speaker_00
Before I talk, I'll bring the parent and the kid both in together and I'll explain that if I think that there's a safety concern, then I will always need to involve your parent, but I would never do that behind your back.

00:29:35 Speaker_00
I would tell you that we needed to involve your parent and then we would come up with a plan of how to do that. Also, if there's a diagnosis that you meet criteria for, I need to talk with your parent about the diagnosis.

00:29:46 Speaker_00
I'm not going to be talking about the specific details of when you use or who you use with, but like if you have a cannabis use disorder or a marijuana use disorder, then I need to talk with your family about what your diagnosis is and what the recommended treatment is.

00:29:58 Speaker_00
And for the most part, kids do okay with that. I think many kids don't think that they will meet criteria for a disorder. And so when they find out they do, they're kind of shocked. And then they sort of are like, uh,

00:30:10 Speaker_00
But they, I think that they realize at that point, like, I guess this is actually a big deal. And so we do need to involve my parents.

00:30:16 Speaker_01
I love that you are, you know, clear and upfront with them, right? I think like, you know, teenagers appreciate being treated like the young adults that they are. We call them young adults, right?

00:30:26 Speaker_01
Like that they that to know this is what the plan is going to be. And just to back up a little bit, I love how you stated the question.

00:30:33 Speaker_01
And again, I think we're certainly taught this in medicine, but sometimes we forget and we have so many things we need to ask about, but not asking a yes or no question opens the door for, I think, better responsiveness.

00:30:43 Speaker_01
Because I think if you asked a teen, hey, are you using, it's so easy just to like reactively say no versus how many times over the last year, at least I think there's going to be a pause to reflect and hopefully be a little bit more honest with their answers.

00:30:57 Speaker_01
So I just wanted to like amplify that bit. And tell us what happens next when and if you think that this would be meaningful for this conversation. Like what reaches the category, for example, of a substance abuse disorder?

00:31:10 Speaker_01
Like you're talking to these teens and they think it's not a problem. Could you talk a little bit more about that? And then what happens?

00:31:17 Speaker_00
Yeah, so every kind of substance and even some behaviors are outlined in the DSM with criteria to distinguish whether or not a person is just using a drug or a substance or if that person actually has a use disorder.

00:31:31 Speaker_00
I think that's really important because I can't tell you how many times you hear like, well, the person's smoking marijuana every day, so clearly they have an addiction.

00:31:41 Speaker_00
And it's like, well, actually there is nowhere in any of the criteria for any of the substances, the amount that the person is using. It's all about how the substance impacts their behavior and their functioning. That's how we define a disorder.

00:31:53 Speaker_00
We don't define it just by the presence of the activity or the thing. And so like an interesting fact that I thought was kind of surprising was that only 50% of daily marijuana users actually have a marijuana use disorder.

00:32:06 Speaker_00
So, and the percentage for alcohol is way higher than that. It's very rare actually to find a daily alcohol user that doesn't meet criteria for an alcohol use disorder. So.

00:32:15 Speaker_01
Very interesting.

00:32:16 Speaker_00
Yeah. So, I mean, it just kind of shows sort of what the different toxic impacts from the substance. And, you know, kids always want to argue with me about, not argue, but just point out, alcohol is so much worse for you and that one's legal.

00:32:28 Speaker_00
And it's like, yeah, I'm not going to disagree with you.

00:32:30 Speaker_01
Well, I know, I know, but it's just sort of like been so like normalized that it's like the better choice.

00:32:38 Speaker_00
Right. Which again, it's like it has its own set of risks. And just because something is better doesn't mean that it's like, yeah, maybe it's better again to ride your bike without a helmet than to ride without a seatbelt.

00:32:46 Speaker_00
But why do you need to choose between those things?

00:32:48 Speaker_01
That's right. That's right. To know that both are risky. And how can you like think ahead and protect yourself? Although, you know, not very many teens are doing a whole lot of thinking ahead, and yet that's not really fair to say because they are.

00:33:00 Speaker_01
They're thinking about maybe what they want to do, things that they enjoy, so I retract that statement.

00:33:05 Speaker_00
Yeah, well, no, I know what you mean. In the moment, it's hard.

00:33:07 Speaker_00
They have impulsive brains, but so anyway, so there's criteria, and so it's actually pretty well defined how you would diagnose a substance use disorder, and so like I can't remember the exact number.

00:33:17 Speaker_00
It might be 11, but there's like 11 different criteria, and then you basically run through the criteria, and they're all the things that you would expect, right? So like you need to use in an increasing

00:33:26 Speaker_00
in increasing amounts to feel a pleasurable effect. If you stop using, you experience withdrawal symptoms. Despite having negative consequences secondary to your use, you continue to use.

00:33:38 Speaker_00
You turn to the substance for help with coping when you're struggling with stress or other difficulties. You've stopped doing other things that you used to enjoy because you prefer to do the substance.

00:33:49 Speaker_00
So there's like a big list of ways to track how it impacts a person's life and then based on how much it's negatively impacting your life is how you determine if it's a mild disorder, a moderate disorder, or a severe disorder.

00:34:02 Speaker_01
Gotcha. So at that point, primary care doctor as a pediatrician or a family doc who's seeing these kiddos, would it be refer at that point for evaluation for treatment or like, where do we go from here?

00:34:15 Speaker_00
Yeah, I, you know, I think if a primary care doc can screen and identify that there's a problem that's a little bit more than just like, I've used it a couple times. So like, let's do some education, right.

00:34:28 Speaker_01
And then you want to, you probably perhaps don't want to have like your whole day full of that.

00:34:31 Speaker_00
Yeah, right. Well, and you know, it's a limited resource, right? So we have to save the resource for the people that need it.

00:34:38 Speaker_00
But I would say if you have a kid who's saying that they're using with any regularity, whether that's like weekly, or if they've really had significant consequences from the use, even if it's not something regular, for example,

00:34:49 Speaker_00
Like, I've had kids where they maybe use marijuana occasionally, they've used other substances occasionally, and then they had a near-fatal overdose on an illicit pill.

00:34:58 Speaker_00
Not that they use illicit pills a lot, but because they are around substances, they thought that would be fun to try, and then something really bad happened. I think it would be reasonable to also refer that kind of kid. to more specialized treatment.

00:35:11 Speaker_00
And when I say specialized treatment, I don't think it has to be anything fancy.

00:35:15 Speaker_00
There are, you know, you can send a kid to go get a comprehensive substance use assessment in the state of Minnesota, which would be like a two-hour appointment where a licensed alcohol drug counselor goes through tons of questions with them and basically determines a level of care that's appropriate to treat them.

00:35:30 Speaker_00
That is an option. I think for some families, that's too daunting. Like, I don't want my kid to be labeled as having a disorder. I don't even know if they have a problem.

00:35:38 Speaker_00
So I think just a referral to a mental health practitioner is a great place to start. That person has a basic working knowledge of screening and diagnosing substance use disorders.

00:35:49 Speaker_00
And if there is a higher degree of need, they can make a more specialized referral from just a general mental health setting. But I think that most primary care

00:35:58 Speaker_00
Like if you wanted to diagnose a substance use disorder, it would be within your purview, but I think it takes time. And so if you want to just identify that there might be a problem, almost like CPS, right?

00:36:08 Speaker_00
You're not supposed to know for sure, but if you feel like there is, you're supposed to turn it over to people who can determine.

00:36:13 Speaker_01
That makes sense. That makes sense. the experts, right? That is so helpful. I feel just like that's such beautiful like information across the board about marijuana and the use out there.

00:36:25 Speaker_01
What haven't we talked about that you think might be helpful or what have I forgotten to ask you about?

00:36:30 Speaker_00
I mean, I think the only other piece that I can think of is and a message that I try to get across is that If we can normalize bringing your child to the doctor to talk about substance use, I think that would be wonderful.

00:36:45 Speaker_00
Meaning if you find out, like me being in this field, my kids are still little, but if I ever found that my daughter had marijuana in her room, one of my first steps would be to, again, talk about how that's not allowed, and then I would bring her to her doctor and say, can you please do a screening

00:37:03 Speaker_00
for substance use with her, like, right, I'll be outside, but like, please, because I like people to think of it as a health issue. It's not like a failing or a personal issue or like any of that.

00:37:15 Speaker_01
Yeah, no, I love it. I love the normalization of it. Right. And I always you and I, I think in our last conversation talked about brain health. And I always say like with mental health issues, same thing.

00:37:24 Speaker_01
It's not a problem that someone is anxious or depressed, like let's get them to the doctor and take the next step. So too for this, let's get them to the expert. It takes us a little bit out of it.

00:37:32 Speaker_01
And we're just like the loving, compassionate parents, right? And let the expert talk about this.

00:37:37 Speaker_01
Just like you tell your kids, like if you have abdominal pain, at least for me as the mom, when they were little, I'd be like, okay, first thing, just try to go to the bathroom.

00:37:44 Speaker_01
And then if it persists, like let's get you in and have someone check it out. Thank you for that. I think that is one of my favorite messages.

00:37:52 Speaker_01
I mean, you've had so many beautiful things to say, but yeah, let's just normalize that this is just another healthcare issue that should be dealt with.

00:37:59 Speaker_00
Yep, exactly.

00:38:00 Speaker_01
Do you find that a lot of parents blame themselves if they, for example, find marijuana in their kid's room or they find out that their child is smoking? I feel like we don't do that with like abdominal pain, but I know that I've heard something.

00:38:15 Speaker_01
But some people like for like even if their kids are struggling in school, like a lot of times there's a little self blame or I don't know. You tell me.

00:38:23 Speaker_01
It's just something I see a lot in my coaching of women physicians that we a lot of times blame ourselves. But I'm just curious in like the real world experience what you see.

00:38:31 Speaker_00
Yeah, no, I think that's the case. And I think kind of as a downstream effect of parents blaming themselves is there's some like inability to identify that as a problem because it creates a lot of guilt and shame for the parent.

00:38:44 Speaker_00
So then they're coping the way they cope with that, not being able to tolerate feeling that way or not wanting to feel that way as they just sort of like push it to the side. And they're like, oh, it's not a big deal. It's normal.

00:38:55 Speaker_00
When like probably part of them knows that maybe it's a big deal and maybe it's not normal, but it's just too shameful. to say that or to identify that your kid might have a problem that it's like easier to just be like, oh, well.

00:39:06 Speaker_01
That's so interesting. So it's sort of just like you put your blinders on, like, I don't want to talk about it. La la la. Versus like, oh, no, this is just another health issue that I'm going to bring them to the doctor for. Brilliant.

00:39:17 Speaker_00
Yeah, and like not to, you know, be scary, but it's like I can think of like three conversations I've had with parents when their child now has an opioid use disorder. And I asked them about the progression of the illness, right?

00:39:29 Speaker_00
And the parent was aware that their child was using marijuana and occasionally drinking alcohol when they were 15, 16 years old, but were sort of like,

00:39:37 Speaker_00
oh no like that's normal it's not an issue and then all of a sudden here they are at the kids like 17 or 18 and they're completely shocked that their kid had an opioid overdose and it's like I guess it's shocking and like it's not like all of a sudden one day your kid woke up and started using pills your kid's actually been using substances for years now and like this is sort of the natural progression of this illness for some people not for everyone but for some people so

00:40:04 Speaker_00
That's why it's important that we take it seriously when it's just marijuana and not just sort of be like, oh, it's fine because it's like that's how you prevent opioid overdose deaths is you intervene when kids are using substances like marijuana and alcohol.

00:40:17 Speaker_01
So good. Quick question about the whole opiate thing because that freaks me out when you mentioned before like a kiddo who was like took something and like had a near fatal like thing like that just freaks me out.

00:40:27 Speaker_01
I mean I had some patients whose children that happened to in my practice and it's just it's devastating and even just thinking about it is devastating and I know that that's a huge problem and

00:40:37 Speaker_01
Again, maybe another conversation for another day, but now that like Narcan is available, I mean, just as an aside, like, is that something that people should have at home just in case?

00:40:45 Speaker_01
I mean, I know we can call 9-1-1, but just give me your thoughts on that, because I know Ramsey County was like, you could just order it for free.

00:40:53 Speaker_00
Yeah, no, 150% yes. I would say, I mean, my kids are little and no one in my family uses opioids that I know of, and I have a Narcan in my little box.

00:41:02 Speaker_01
Yeah, I ordered it too. I mean, just I'm like, again, we don't use this. I mean, but God forbid I have kids. who have friends over or, God forbid, somebody comes over and offers something. I just think, wow.

00:41:15 Speaker_00
Yeah. No, I think because it's accessible, I think we should all have it. Of course, you're always going to call 911 also. Of course. Oh my goodness. You can, I mean, really, what do they say? Time is brain cells, right?

00:41:28 Speaker_00
And so if you've called 911 and whoever it is, someone's down, if you can give them Narcan and get their breathing rate up a little bit so they're getting some oxygen, that's going to help protect their brain until EMS can get there.

00:41:43 Speaker_01
And here's another just question again. I'm so naive, but I'm learning are, you know, I know that pills can certainly be laced, but can like marijuana also be laced with fentanyl, that sort of thing?

00:41:53 Speaker_00
It can be really anything can be laced with anything. I mean, that's kind of the moral of the story. I would say that, like, is it a huge problem that my patients that use marijuana are accidentally getting fentanyl? No. I mean, fentanyl is expensive.

00:42:08 Speaker_00
I mean, it's not expensive compared to other things, but it's not I don't think it's like It's not common.

00:42:13 Speaker_01
So again, this is my worst case scenario.

00:42:17 Speaker_00
I would say that's not a common occurrence. It's possible, yes, it's not common.

00:42:22 Speaker_00
I would say what is really common, and I think I look at this occasionally, but Minnesota DEA will talk about what the contents of the seized pills have been within the state or the region.

00:42:32 Speaker_00
And I think in Minnesota right now, it's something like 80% or more of all illicit pills, regardless of what they're supposed to be, have fentanyl in them.

00:42:41 Speaker_00
And so if you have a kid that's using pills, even if they say they're, you know, Benzos or Xanaxes or whatever, Molly, or whatever they think that the pill is, it probably has fentanyl in it.

00:42:54 Speaker_00
So that's typically where we're seeing it is in kids that are using pills. Got it.

00:42:59 Speaker_01
Terrifying. Don't do it. But that's my my wisdom. But what I'm hearing you say and just to kind of reiterate and bring it back is like, yes, there are teens using marijuana and not everybody. It's a very low percentage that's using it on the regular.

00:43:13 Speaker_01
And let's be clear with our kids what our expectations are and clear with our consequences and get in to see the doctor if we have concerns.

00:43:21 Speaker_00
Yes. Beautiful. That was a beautiful summary. I couldn't have said it better.

00:43:26 Speaker_01
I love little succinct wrap up. I so appreciate you taking the time to just let us all see what's really going on. And now what do we deal with it? I mean, we don't need to be scared about it. It's out there.

00:43:38 Speaker_01
Like, let's take the blinders off and just like have conversations with our kids and what our expectations are. I mean, that's my big takeaway and just like normalize, okay, this is out there. And now how are we going to move forward?

00:43:49 Speaker_01
Talk about how, if people have concerns, I know last time we talked about how you're this amazing psychiatrist and have availability for folks.

00:43:56 Speaker_01
Tell us a little bit more about the work that you do, who you love to help, and how people can contact you.

00:44:02 Speaker_00
Yeah, so I work at Ellie Mental Health and I have an outpatient clinic. I specialize teens and young adults that have co-occurring illness, and so that's substance use and mental health. I'm open to new patients in my clinic.

00:44:14 Speaker_00
I'm booking out a couple of weeks now for new patient intakes, but I would love to consult, See kids, see families. I also work with kids of healthcare providers, even if there's not substance use, but just for general child adolescent psychiatry.

00:44:27 Speaker_00
So yeah, people can contact Ellie Mental Health. The phone number is 651-313-8080. Press number two, and that's the medication management, and then they can request to schedule with me.

00:44:39 Speaker_01
Beautiful. I will put those links in the show notes because I know you do an amazing job and I'm so grateful for the work of all my fellow physicians.

00:44:47 Speaker_01
But I think there's something particularly amazing about people who help people through what I would call just like rougher times, right? Like with mental health issues and substance abuse issues.

00:44:56 Speaker_01
And it is just a disease like if you have heart problems. So like I love that you're there, help people take good care of their brains and their health. So.

00:45:04 Speaker_01
Thank you so much, Sarah, for being here and for winning the award of being the first one back for the second time. I am so grateful for you taking time to share your wisdom with all my listeners. Well, thank you so much. Thank you.

00:45:20 Speaker_01
Are you ready to take control of your life and put these tools into action? I'm here to help. I offer free consultations for physician moms to see if my one-on-one coaching package is right for you.

00:45:32 Speaker_01
You can sign up for a free consult at www.MamaDocLifeCoach.com